Provider Demographics
NPI:1649036385
Name:HEATH, LISA MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HEATH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 KIGER LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26060-5998
Mailing Address - Country:US
Mailing Address - Phone:304-281-6999
Mailing Address - Fax:
Practice Address - Street 1:299 WV-2
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155
Practice Address - Country:US
Practice Address - Phone:304-455-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1495224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant